PhD Study Provides Evidence for Clinical Management of TB/HIV Co-Infection

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A UKZN PhD study in Public Health Medicine has generated evidence for policy and clinical management of patients with HIV and TB co-infection.

Conducted by the Head of the Treatment Research Programme at the Centre of the AIDS Programme of Research in South Africa (CAPRISA), Dr Kogie Naidoo, the research assessed and identified strategies to overcome clinical and programmatic challenges when integrating HIV and TB care to reduce co-infection mortality.

‘Integration of HIV and TB treatment is key to reducing mortality in co-infected patients; especially in sub-Saharan Africa where TB-HIV co-infection rates reach 80%,’ Naidoo said.

She said many obstacles impeded the effective scale-up of HIV-TB integration, extending from the clinical complexities in individual patient management, to impediments in health service organisation and prioritisation.

‘The new information generated by this study provides important evidence for policy and clinical management of patients with HIV and TB co-infection,’ she said

The study found that careful clinical vigilance for ‘unmasked’ TB was required in patients initiating ART (antiretrovirals).

It also found that the survival benefit of AIDS therapy in TB patients could be maximised by initiating ART as soon as possible after TB therapy start especially in patients with advanced immunosuppression, i.e., those with CD4+ counts <50 cells/mm³.

‘However, patients with higher CD4+ cell counts should delay ART initiation to at least eight weeks after the start of TB therapy to minimise the incidence and duration of immune reconstitution disease and consequent hospitalisation.

Naidoo said: ‘This approach, which is at variance with current World Health Organization policy and guidelines, is cost-effective and readily implementable within the clinical setting.’

According to Naidoo, addressing the operational challenges to HIV-TB treatment integration could improve patient outcomes with substantial public health impact by reducing mortality by the most important causes of death in South Africa.

‘My research on immune reconstitution inflammatory syndrome, IRIS and rifampicin-efavirenz drug interactions has been influential in defining treatment strategies for these common complications of integrating TB-HIV treatment,’ declared Naidoo.

Naidoo’s work has led to changes in multiple local and international guidelines including the WHO, the US government DHHS, the British HIV Association and the South African national treatment guidelines in the management of TB HIV co-infected patients.

She was awarded the 2013 Union Scientific Prize by the International Union Against Tuberculosis and Lung Disease in recognition for the work emanating from her PhD thesis.

‘We have been awarded R10 million from the SA MRC Newton Fund to conduct this study, which is currently underway in rural public health clinics in KwaZulu-Natal,’ she said.

She is the  Principal Investigator (PI) in a study evaluating TB recurrence in TB-HIV co-infected patients, previously successfully treated for TB, with the aim of better understanding whether exogenous re-infection or relapse of previous TB infection is responsible for recurrent TB in stable HIV infected patients on ART.  

She is also a PI of the CAPRISA Advanced Clinical Care Award which aims to establish regional capability for advanced clinical management of patients with HIV/AIDS, TB and drug resistant TB in all districts within KwaZulu-Natal. ‘This project is being undertaken with technical input from several leading academics from the Health Sciences,’ said Naidoo.

 Nombuso Dlamini